Consumption of Alcohol Harmful for People with HIV

Safe drinking limits for people living with HIV may need to be lower than the recommendations for the rest of the population, according to a large American study. The drinking habits and health outcomes of over 18,000 men living with HIV were compared with those of over 42,000 men who didn’t have HIV. Most participants were in their forties, fifties and sixties.

Alcohol contributes to a wide range of cancers, liver disease, stroke and heart disease.

Looking at deaths from any cause, the researchers found a strong relationship between the amount people with HIV drank and their risk of death. After adjusting for other factors that could influence the results, men who had 30 to 70 alcoholic drinks a month (i.e. one or two a day) had a 30% higher risk of death than men who hardly drank at all. Men who drank more than this (70 or more drinks a month) had a 50% greater risk.

In contrast, only the higher level of drinking (70 or more a month) made a difference to deaths in HIV-negative men.

There were similar results when looking at results of blood tests, liver function tests and other markers of poorer health – there wasn’t any level of alcohol consumption which was ‘safe’ for men with HIV.

One limitation of the study is that it only includes data on men. Nonetheless, the greater harm caused by a unit of alcohol in women is well established. The overall findings probably apply to women, but at lower levels of alcohol consumption.

Some other studies suggest that a person living with HIV who consumes the same amount of alcohol as an HIV-negative person would have higher levels of alcohol in their blood than the person without HIV. This effect may be especially pronounced in people who aren’t taking HIV treatment.

The researchers concluded that people with HIV who drink more than 30 alcoholic drinks a month are at increased risk of health problems. This was an American study, using American standard drinks – for example, one drink is a small can of beer, a small glass of wine or a shot of whisky. No more than 30 drinks a month would amount to no more than one drink a day.

UK health authorities calculate alcohol quantities differently, but recently released advice from the Chief Medical Officer is consistent with the recommendations of the American study. One “unit” of alcohol in the UK is roughly half of a standard drink in the US. The UK government now recommends alcohol consumption below 14 units a week, which is the same as 8 American standard drinks a week – i.e. roughly one drink a day. 

However very few people in the general population and even fewer people with HIV drink this little. But this is the first major study to show that there are particular advantages for people living with HIV to cut back on alcohol.

Infant and Young Child Feeding

Key facts

Every infant and child has the right to good nutrition according to the Convention on the Rights of the Child.

Under nutrition is associated with 45% of child deaths.

Globally in 2013, 161.5 million children under 5 were estimated to be stunted, 50.8 million were estimated to have low weight-for-height, and 41.7 million were overweight or obese.

About 36% of infants 0 to 6 months old are exclusively breastfed.

Few children receive nutritionally adequate and safe complementary foods; in many countries less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are appropriate for their age.

Over 800 000 children's lives could be saved every year among children under 5, if all children 0–23 months were optimally breastfed . Breastfeeding improves IQ, school attendance, and is associated with higher income in adult life. 1

Improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level.

Overview

Under nutrition is estimated to cause 3.1 million child deaths annually or 45% of all child deaths. Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall.

Optimal breastfeeding is so critical that it could save over 800 000 under 5 child lives every year.

WHO and UNICEF recommend:

early initiation of breastfeeding within 1 hour of birth;

exclusive breastfeeding for the first 6 months of life; and

introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about 36% of infants aged 0 to 6 months worldwide are exclusively breastfed over the period of 2007-2014.

Recommendations have been refined to also address the needs for infants born to HIV-infected mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6 months old and continue breastfeeding until at least 12 months of age with a significantly reduced risk of HIV transmission.

Breastfeeding

Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief among these is protection against gastrointestinal infections which is observed not only in developing but also industrialized countries. Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infections and reduces newborn mortality. The risk of mortality due to diarrhoea and other infections can increase in infants who are either partially breastfed or not breastfed at all.

Breast milk is also an important source of energy and nutrients in children aged 6 to 23 months. It can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness, and reduces mortality among children who are malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight/obese. Additionally, they perform better on intelligence tests and have higher school attendance. Breastfeeding is associated with higher income in adult life. Improving child development and reducing health costs result in economic gains for individual families as well as at the national level.1

Longer durations of breastfeeding also contribute to the health and well-being of mothers; it reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions that help protect, promote and support breastfeeding include:

adoption of policies such as the International Labour Organization’s Maternity Protection Convention 183 and Recommendation No. 191, which complements Convention No. 183 by suggesting a longer duration of leave and higher benefits;

the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;

implementation of the Ten Steps to Successful Breastfeeding specified in the Baby-Friendly Hospital Initiative, including:

skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;

breastfeeding on demand (that is, as often as the child wants, day and night);

rooming-in (allowing mothers and infants to remain together 24 hours a day);

not giving babies additional food or drink, even water, unless medically necessary;

provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and

community support, including mother support groups and community-based health promotion and education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding

Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. 

Guiding principles for appropriate complementary feeding are:

continue frequent, on-demand breastfeeding until 2 years of age or beyond;

practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);

practise good hygiene and proper food handling;

start at 6 months with small amounts of food and increase gradually as the child gets older;

gradually increase food consistency and variety;

increase the number of times that the child is fed: 2-3 meals per day for infants 6-8 months of age and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required;

use fortified complementary foods or vitamin-mineral supplements as needed; and

during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances

Families and children in difficult circumstances require special attention and practical support. Wherever possible, mothers and babies should remain together and get the support they need to exercise the most appropriate feeding option available. Breastfeeding remains the preferred mode of infant feeding in almost all difficult situations, for instance:

low-birth-weight or premature infants;

HIV-infected mothers;

adolescent mothers;

infants and young children who are malnourished; and

families suffering the consequences of complex emergencies.

HIV and infant feeding

Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant ways to improve infant survival rates. However, HIV can pass from mother to child during pregnancy, labour or delivery, and also through breast milk. In the past, the challenge was to balance the risk of infants acquiring HIV through breastfeeding versus the higher risk of death from causes other than HIV, in particular malnutrition and serious illnesses such as diarrhea and pneumonia, among HIV-exposed but still uninfected infants who were not breastfed.

The evidence on HIV and infant feeding shows that giving antiretroviral drugs (ARVs) to HIV-infected mothers can significantly reduce the risk of transmission through breastfeeding and also improve her health. This enables infants of HIV-infected mothers to be breastfed with a low risk of transmission (1-2%). HIV-infected mothers and their infants living in countries where diarrhoea, pneumonia and malnutrition are still common causes of infant and child deaths can therefore gain the benefits of breastfeeding with minimal risk of HIV transmission.

Since 2010, WHO has recommended that mothers who are HIV-infected take ARVs and exclusively breastfeed their babies for 6 months, then introduce appropriate complementary foods and continue breastfeeding up to the child’s first birthday. Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.

Even when ARVs are not available, mothers should be counselled to exclusively breastfeed for 6 months and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, feeding with infant formula.

WHO's response

WHO is committed to supporting countries with implementation and monitoring of the "Comprehensive implementation plan on maternal, infant and young child nutrition", endorsed by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by 2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that will help to achieve this include those outlined in the "Global Strategy for Infant and Young Child Feeding", which aims to protect, promote and support appropriate infant and young child feeding.

WHO has formed a Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions called NetCode. The goal of NetCode is to protect and promote breastfeeding by ensuring that breastmilk substitutes are not marketed inappropriately. Specifically, NetCode is building the capacity of Member States and civil society to strengthen national Code legislation, continuously monitor adherence to the Code, and take action to stop all violations. In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child transmission, good nutrition of the baby, and protect the health of the mother.

Healthy Diet

Key facts
A healthy diet helps protect against malnutrition in all its forms, as well as noncommunicable diseases (NCDs), including diabetes, heart disease, stroke and cancer.

Unhealthy diet and lack of physical activity are leading global risks to health.

Healthy dietary practices start early in life – breastfeeding fosters healthy growth and improves cognitive development, and may have longer-term health benefits, like reducing the risk of becoming overweight or obese and developing NCDs later in life.

Energy intake (calories) should be in balance with energy expenditure. Evidence indicates that total fat should not exceed 30% of total energy intake to avoid unhealthy weight gain , with a shift in fat consumption away from saturated fats to unsaturated fats , and towards the elimination of industrial trans fats .

Limiting intake of free sugars to less than 10% of total energy intake  is part of a healthy diet. A further reduction to less than 5% of total energy intake is suggested for additional health benefits.

Keeping salt intake to less than 5 g per day helps prevent hypertension and reduces the risk of heart disease and stroke in the adult population.

WHO Member States have agreed to reduce the global population’s intake of salt by 30% and halt the rise in diabetes and obesity in adults and adolescents as well as in childhood overweight by 2025.

Overview

Consuming a healthy diet throughout the life course helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases and conditions. But the increased production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars or salt/sodium, and many do not eat enough fruit, vegetables and dietary fiber such as whole grains.

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual needs (e.g. age, gender, lifestyle, degree of physical activity), cultural context, locally available foods and dietary customs. But basic principles of what constitute a healthy diet remain the same.

For adults

A healthy diet contains:

Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice).

At least 400 g (5 portions) of fruits and vegetables a day. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables.

Less than 10% of total energy intake from free sugars  which is equivalent to 50 g (or around 12 level teaspoons) for a person of healthy body weight consuming approximately 2000 calories per day, but ideally less than 5% of total energy intake for additional health benefits . Most free sugars are added to foods or drinks by the manufacturer, cook or consumer, and can also be found in sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Less than 30% of total energy intake from fats. Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, canola and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard) . Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet.

Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use iodized salt.

For infants and young children

In the first 2 years of a child’s life, optimal nutrition fosters healthy growth and improves cognitive development. It also reduces the risk of becoming overweight or obese and developing NCDs later in life.

Advice on a healthy diet for infants and children is similar to that for adults, but the following elements are also important.

Infants should be breastfed exclusively during the first 6 months of life.

Infants should be breastfed continuously until 2 years of age and beyond.

From 6 months of age, breast milk should be complemented with a variety of adequate, safe and nutrient dense complementary foods. Salt and sugars should not be added to complementary foods.

Practical advice on maintaining a healthy diet

Fruits and vegetables

Eating at least 400 g, or 5 portions, of fruits and vegetables per day reduces the risk of NCDs , and helps ensure an adequate daily intake of dietary fiber.

In order to improve fruit and vegetable consumption you can:

always include vegetables in your meals

eat fresh fruits and raw vegetables as snacks

eat fresh fruits and vegetables in season

eat a variety of choices of fruits and vegetables.

Fats

Reducing the amount of total fat intake to less than 30% of total energy intake helps prevent unhealthy weight gain in the adult population.

Also, the risk of developing NCDs is lowered by reducing saturated fats to less than 10% of total energy intake, and trans fats to less than 1% of total energy intake, and replacing both with unsaturated fats.

Fat intake can be reduced by:

changing how you cook – remove the fatty part of meat; use vegetable oil (not animal oil); and boil, steam or bake rather than fry;

avoiding processed foods containing trans fats; and

limiting the consumption of foods containing high amounts of saturated fats (e.g. cheese, ice cream, fatty meat).

Salt, sodium and potassium

Most people consume too much sodium through salt (corresponding to an average of 9–12 g of salt per day) and not enough potassium. High salt consumption and insufficient potassium intake (less than 3.5 g) contribute to high blood pressure, which in turn increases the risk of heart disease and stroke.

1.7 million deaths could be prevented each year if people’s salt consumption were reduced to the recommended level of less than 5 g per day.

People are often unaware of the amount of salt they consume. In many countries, most salt comes from processed foods (e.g. ready meals; processed meats like bacon, ham and salami; cheese and salty snacks) or from food consumed frequently in large amounts (e.g. bread). Salt is also added to food during cooking (e.g. bouillon, stock cubes, soy sauce and fish sauce) or at the table (e.g. table salt).

You can reduce salt consumption by:

not adding salt, soy sauce or fish sauce during the preparation of food

not having salt on the table

limiting the consumption of salty snacks

choosing products with lower sodium content.

Some food manufacturers are reformulating recipes to reduce the salt content of their products, and it is helpful to check food labels to see how much sodium is in a product before purchasing or consuming it.

Potassium, which can mitigate the negative effects of elevated sodium consumption on blood pressure, can be increased with consumption of fresh fruits and vegetables.

Sugars

The intake of free sugars should be reduced throughout the lifecourse. Evidence indicates that in both adults and children, the intake of free sugars should be reduced to less than 10% of total energy intake, and that a reduction to less than 5% of total energy intake provides additional health benefits . Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to overweight and obesity.

Sugars intake can be reduced by:

limiting the consumption of foods and drinks containing high amounts of sugars (e.g. sugar-sweetened beverages, sugary snacks and candies); and eating fresh fruits and raw vegetables as snacks instead of sugary snacks.

How to promote healthy diets

Diet evolves over time, being influenced by many factors and complex interactions. Income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, as well as geographical, environmental, social and economic factors all interact in a complex manner to shape individual dietary patterns. Therefore, promoting a healthy food environment, including food systems which promote a diversified, balanced and healthy diet, requires involvement across multiple sectors and stakeholders, including government, and the public and private sector.

Governments have a central role in creating a healthy food environment that enables people to adopt and maintain healthy dietary practices.

Effective actions by policy-makers to create a healthy food environment include:

Creating coherence in national policies and investment plans, including trade, food and agricultural policies, to promote a healthy diet and protect public health:

Increase incentives for producers and retailers to grow, use and sell fresh fruits and vegetables;

Reduce incentives for the food industry to continue or increase production of processed foods with saturated fats and free sugars;

Encourage reformulation of food products to reduce the contents of salt, fats (i.e. saturated fats and trans fats) and free sugars;

Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children;

Establish standards to foster healthy dietary practices through ensuring the availability of healthy, Safe and affordable food in pre-schools, schools, other public institutions, and in the workplace;

Sxplore regulatory and voluntary instruments, such as marketing and food labelling policies, Economic incentives or disincentives (i.e. taxation, subsidies), to promote a healthy diet; and

encourage transnational, national and local food services and catering outlets to improve the nutritional quality of their food, ensure the availability and affordability of healthy choices, and review portion size and price.

Encouraging consumer demand for healthy foods and meals:

Promote consumer awareness of a healthy diet,

Develop school policies and programmes that encourage children to adopt and maintain a healthy diet;

Educate children, adolescents and adults about nutrition and healthy dietary practices;

Encourage culinary skills, including in schools;

Support point-of-sale information, including through food labelling that ensures accurate, Standardized and comprehensible information on nutrient contents in food in line with the Codex Alimentarius Commission guidelines; and

provide nutrition and dietary counselling at primary health care facilities.

Promoting appropriate infant and young child feeding practices:

Implement the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;

Implement policies and practices to promote protection of working mothers; and

Promote, protect and support breastfeeding in health services and the community, including through the Baby-friendly Hospital Initiative.

WHO response

The “WHO Global Strategy on Diet, Physical Activity and Health” (12) was adopted in 2004 by the World Health Assembly (WHA). It called on governments, WHO, international partners, the private sector and civil society to take action at global, regional and local levels to support healthy diets and physical activity.

In 2010, the WHA endorsed a set of recommendations on the marketing of foods and non-alcoholic beverages to children (13). These recommendations guide countries in designing new policies and improving existing ones to reduce the impact on children of the marketing of unhealthy food. WHO is also helping to develop a nutrient profile model that countries can use as a tool to implement the marketing recommendations.

In 2012, the WHA adopted a “Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition” and 6 global nutrition targets to be achieved by 2025, including the reduction of stunting, wasting and overweight in children, the improvement of breastfeeding and the reduction of anaemia and low birth weight (7).

In 2013, the WHA agreed to 9 global voluntary targets for the prevention and control of NCDs, which include a halt to the rise in diabetes and obesity and a 30% relative reduction in the intake of salt by 2025. The “Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020” (8) provides guidance and policy options for Member States, WHO and other UN agencies to achieve the targets.

With many countries now seeing a rapid rise in obesity among infants and children, in May 2014 WHO set up the Commission on Ending Childhood Obesity. The Commission is developing a report specifying which approaches and actions are likely to be most effective in different contexts around the world.

In November 2014, WHO organized, jointly with the Food and Agriculture Organization of the United Nations (FAO), the Second International Conference on Nutrition (ICN2). ICN2 adopted the Rome Declaration on Nutrition (14) and the Framework for Action (15), which recommends a set of policy options and strategies to promote diversified, safe and healthy diets at all stages of life. WHO is helping countries to implement the commitments made at ICN2.

Sexually Transmitted Infections

Key facts

More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide.

Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV).

More than 290 million women have a human papillomavirus (HPV) infection.2

The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI.

STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition.

In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission)

Drug resistance, especially for gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

What are sexually transmitted infections and how are they transmitted?

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex. Some STIs can also be spread through non-sexual means such as via blood or blood products. Many STIs—including chlamydia, gonorrhoea, primarily hepatitis B, HIV, and syphilis—can also be transmitted from mother to child during pregnancy and childbirth.

A person can have an STI without having obvious symptoms of disease. Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.

Scope of the problem

STIs have a profound impact on sexual and reproductive health worldwide.

More than 1 million STIs are acquired every day. Each year, there are estimated 357 million new infections with 1 of 4 STIs: chlamydia (131 million), gonorrhoea (78 million), syphilis (5.6 million) and trichomoniasis (143 million). More than 500 million people are living with genital HSV (herpes) infection. At any point in time, more than 290 million women have an HPV infection, one of the most common STIs.

STIs can have serious consequences beyond the immediate impact of the infection itself.

STIs like herpes and syphilis can increase the risk of HIV acquisition three-fold or more.

Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. Syphilis in pregnancy leads to approximately 305 000 fetal and neonatal deaths every year and leaves 215 000 infants at increased risk of dying from prematurity, low-birth-weight or congenital disease.1

HPV infection causes 528 000 cases of cervical cancer and 266 000 cervical cancer deaths each year.2

STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease (PID) and infertility in women.

Prevention of STIs

Counselling and behavioural approaches

Counselling and behavioural interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:

comprehensive sexuality education, STI and HIV pre- and post-test counseling;

safer sex/risk-reduction counselling, condom promotion;

interventions targeted at key populations, such as sex workers, men who have sex with men and people who inject drugs; and

education and counseling tailored to the needs of adolescents.

In addition, counseling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training of health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.

Barrier methods

When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

Diagnosis of STIs

Accurate diagnostic tests for STIs are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, in low- and middle-income countries, diagnostic tests are largely unavailable. Where testing is available, it is often expensive and geographically inaccessible; and patients often need to wait a long time (or need to return) to receive results. As a result, follow up can be impeded and care or treatment can be incomplete.

The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. The syphilis test is already in use in some resource-limited settings. The test is accurate, can provide results in 15 to 20 minutes, and is easy to use with minimal training. Rapid syphilis tests have been shown to increase the number of pregnant women tested for syphilis. However, increased efforts are still needed in most low- and middle-income countries to ensure that all pregnant women receive a syphilis test.

Several rapid tests for other STIs are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.

Treatment of STIs

Effective treatment is currently available for several STIs.

Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic STI (trichomoniasis) are generally curable with existing, effective single-dose regimens of antibiotics.

For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease.

For hepatitis B, immune system modulators (interferon) and antiviral medications can help to fight the virus and slow damage to the liver.

Resistance of STIs—in particular gonorrhoea—to antibiotics has increased rapidly in recent years and has reduced treatment options. The emergence of decreased susceptibility of gonorrhoea to the “last line” treatment option (oral and injectable cephalosporins) together with antimicrobial resistance already shown to penicillins, sulphonamides, tetracyclines, quinolones and macrolides make gonorrhoea a multidrug-resistant organism. Antimicrobial resistance for other STIs, though less common, also exists, making prevention and prompt treatment critical.

STI case management

Low- and middle-income countries rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This is called syndromic management. This approach, which often relies on clinical algorithms, allows health workers to diagnose a specific infection on the basis of observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, abdominal pain).

Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes - the majority of STIs globally.

Vaccines and other biomedical interventions

Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. The vaccine against hepatitis B is included in infant immunization programmes in 93% of countries and has already prevented an estimated 1.3 million deaths from chronic liver disease and cancer.

HPV vaccine is available as part of routine immunization programmes in 65 countries, most of them high- and middle-income. HPV vaccination could prevent the deaths of more than 4 million women over the next decade in low- and middle-income countries, where most cases of cervical cancer occur, if 70% vaccination coverage can be achieved.

Research to develop vaccines against herpes and HIV is advanced, with several vaccine candidates in early clinical development. Research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis is in earlier stages of development.

Other biomedical interventions to prevent some STIs include adult male circumcision and microbicides.

Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60% and provides some protection against other STIs, such as herpes and HPV.

Tenofovir gel, when used as a vaginal microbicide, has had mixed results in terms of the ability to prevent HIV acquisition, but has shown some effectiveness against HSV-2.

Current efforts to contain the spread of STIs are not sufficient

Behaviour change is complex

Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, consult extensively with the identified target populations, and involve them in design, implementation and evaluation.

Health services for screening and treatment of STIs remain weak

People seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services, and little or no follow-up of sexual partners.

In many countries, STI services are provided separately and not available in primary health care, family planning and other routine health services.

In many settings, services are often unable to provide screening for asymptomatic infections, lacking trained personnel, laboratory capacity and adequate supplies of appropriate medicines.

Marginalized populations with the highest rates of STIs—such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations and adolescents—often do not have access to adequate health services.

WHO response

WHO develops global norms and standards for STI treatment and prevention, strengthens systems for surveillance and monitoring, including those for drug-resistant gonorrhoea, and leads the setting of the global research agenda on STIs.

Our work is currently guided by the Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006-2015, adopted by the World Health Assembly in 2006, and the 2015 United Nations Global Strategy for Women's, Children's and Adolescents’ Health, which highlight the need for a comprehensive, integrated package of essential interventions, including information and services for the prevention of HIV and other sexually transmitted infections. WHO is developing 3 new 2016-2021 Global Health Sector Strategies for HIV/AIDS, Viral Hepatitis, and STIs.

WHO works with countries to:

Scale-up effective STI services including:

STI case management and counseling

syphilis testing and treatment, in particular for pregnant women

hepatitis B and HPV vaccination.

Promote strategies to enhance STI-prevention impact including:

integrate STI services into existing health systems

promote sexual health

measure the burden of STIs

monitor and respond to STI antimicrobial resistance.

Support the development of new technologies for STI prevention such as:

point-of care diagnostic tests for STIs

additional drugs for gonorrhoea

STI vaccines and other biomedical interventions.

How Lifestyle Impacts Your Health

Starting in the mid-20th century, the primary causes of death worldwide shifted from infections to chronic conditions, such as heart disease and cancer. The School has meticulously documented this change, standing at the forefront of both basic and applied research. Its discoveries in nutrition, exercise, and other individual risk factors have reconfigured the public health landscape.

The Nurses’ Health Study I, ­ a collaboration begun in 1976 among School scientists and researchers at Brigham and Women’s Hospital and the Channing Laboratory, ­ was the first of a series of prospective cohort investigations, now among the largest and oldest in the world. The study produced a lengthy list of surprising findings. Among these: that a high-fat diet increases colon cancer risk but not breast cancer risk; that weight gain after adolescence raises death rates in midlife; and that light smoking more than doubles the risk of heart disease. The Physicians’ Health Study showed that an aspirin a day reduces the risk of heart attack.

The School’s Department of Nutrition, founded in 1942, was the first such department in a medical or public health school in the world. Its groundbreaking research includes work on the health benefits and hazards of proteins and fats; the components of a well-balanced diet; and clinical aspects of obesity. School scientists created the first animal model for hypercholesterolemia and demonstrated the protective nature of HDL cholesterol and the blood vessel-damaging potential of LDL cholesterol.

In the 1970s, School scientists helped map the government’s Dietary Guidelines for Americans; decades later, they proposed an alternative Healthy Eating Pyramid based on the Mediterranean diet and including recommendations for daily exercise and weight control. In 2006, when the U.S. Food and Drug Administration ordered that nutrition labels for packaged foods list all harmful trans fatty acids, it signified a victory for School scientists, led by Walter Willett. A vigorous public health advocate, Willett not only amassed evidence that these solid fats raise the risk of coronary artery disease, type 2 diabetes, and other ills, but also waged a campaign to label and ultimately eliminate the ingredient from manufactured food products and restaurant meals.

Established in 1988, the Center for Health Communication has used entertainment media and mass communication to shift social norms in healthier directions. Among its innovations, it worked with Hollywood to incorporate the Swedish-originated designated-driver concept into entertainment programming, which decreased alcohol-related traffic crashes. So successful were the School’s efforts that the Random House Webster’s College Dictionary (1991 edition) added “designated driver” to the American lexicon.

In a similar vein, School faculty have led the charge for worldwide tobacco control, providing the scientific expertise to convince nations in Europe and Asia to pass smoking bans for public places. In a pair of 2008 studies, School investigators revealed a deliberate strategy among tobacco companies to recruit and addict young smokers by manipulating menthol content and by heavily advertising in places that cater to youth.

In 2008, School researchers published the largest and longest-running study to estimate the impact of a combination of lifestyle factors on mortality. The study concluded that not smoking, maintaining a healthy weight, regular physical activity, and a nutritious diet dramatically lowered the risk of dying from all causes during the 24 years of the study. In 2009, resolving a long-simmering scientific and popular debate, School investigators found that diets that reduced calories led to weight loss, ­ regardless of the proportion of carbohydrates, protein, or fat.

How Lifestyle Impacts Your Health

Lifestyle includes the behavior and activities that make up your daily life. This includes:

• the work you do

• your leisure activities

• the food you eat 

• your interaction with family, friends, neighbors,coworkers and strangers. 

Making Decisions about the Way You Live:

People make decisions based on beliefs, attitudes,and values. Our life experience and interaction with others also shapes our thoughts and actions.Personal behavior is affected by the information you learn at home and school, and from the radio,newspapers, and television. The good news is:

you can change the way you live

Thinking about changing your lifestyle?

• Pay attention to the way you live (or your lifestyle and health habits) and the work you do every day. 

• Talk with friends and family about lifestyle and health decisions.

• Discuss what you may want to change with them.

• Improve the quality of life for you and your family

Make a Healthy Choice Today!

Making Decisions about the Foods We Eat:
The foods we eat affect on our health. Many studies show that good nutrition lowers the risk for many diseases. Our food habits can bring on heart disease, stroke, some types of cancer, diabetes, and osteoporosis …or help prevent them!

You may like to eat foods from your family’s country of origin, following their customs and traditions. You can usually improve traditional family recipes for better health by substituting ingredients.

Make a Family Recipe Book: 

• Collect family recipes in a booklet.

• Share the recipes with a nutrition expert and find out which recipes are healthy ones. 

• Ask how to change some ingredients of old favorites that are sort of unhealthy. 

• Make those changes to the recipes and taste them with your family.

• Share the book of healthier recipes with everyone in your family

Change the way you eat. It can be fun and tasty

Work and Leisure Activities

The work we do affects our health. Apart from exposure to environmental hazards such as UV radiation and toxic chemicals like smoke, asbestos or pesticides, certain types of work involve prolonged repetitive actions and/or reduced levels of activity that may lead to muscular or skeletal problems, strained vision, and other health problems

Even the person with the busiest schedule can make room for stretching, physical activity, and having fun. Before or after work or before meals might be a good time to do this. Think about your daily schedule and look for ways to be more active

Tips for Becoming More Active:

• Walk as much as possible 

• Park the car farther away 

• Take the stairs instead of the elevator or escalator

• Try gardening or home repair activities

• Dance!

Studies have shown that regular mild aerobic exercise four times a week may help lower cholesterol, reduce the risk of heart disease, and improve diabetes management.

Leisure activities such as reading, playing cards, listening to music, and other pastimes have also been shown to have a positive impact on health by reducing stress.

Steps to Healthy Eating:

• Make good nutrition part of every day living. 

• Eat healthy at home, work and play. 

• Eating healthier will make you be and feel healthier.

Tips for Healthy Eating: 

• Eat at least 5-9 servings of fruits and vegetables every day. Try them canned, frozen, or as juice. 

• Choose whole grain bread and cereal. 

• Choose low-fat milk and cheeses. 

• Choose lean meats, poultry, fish. 

• Eat more beans and grains 

• Use less salt, sugar, alcohol, and saturated fat. 

• Drink lots of water between meals.

Other Things You Can Do to Stay Healthy: 

• If you smoke now, quit! 

• Get a handle on stress! 

• If you drink alcohol, beer, or wine only drink in moderation

Lifestyle-based analytics hold promise for proactive care

Lifestyle-based analytics may be an "emerging" predictive health model, but experts note that it's "simply taking data that we already have at our fingertips" and analyzing it in ways that weren't possible before.

The benefit? “Moving from a reactive mode to a proactive mode” in healthcare, says Chris Stehno, senior manager at Deloitte Consulting.

In the past, predictive healthcare modeling has used claims data, but the majority of the population doesn’t have good data – making predictions about life events and diseases difficult.

Stehno says their model uses consumer spending data, which is “chock-full“ of information on how individuals lead their lives. This data also provides high correlations for lifestyle-based diseases, which account for 75 percent of the total medical dollars spent in the U.S.

As Bill Preston, a principal at Deloitte, points out, when a person changes addresses, he or she starts getting bombarded with offerings for new siding – because consumer data indicates they're a new home buyer. Preston says their model takes that same data and it mines it for “specific variables that will be indicative of a particular situation or disease.”

For instance, Preston and Stehno note studies that have shown that individuals with a commute of 90 minutes or longer round-trip are 20 percent more likely to become diabetic or obese.

“Where in claims data you know for sure that they have a condition,” in the lifestyle based analytics, “this information doesn’t tell you that [this individual] has diabetes it tells you that they have an elevated risk for diabetes," says Stehno.

Preston notes that this can allow health insurers and providers to be proactive and not wait to do something until they are sick, which lowers overall healthcare spending.

But the model can also indicate an individual's “willingness to change.” For example, says Stehno, if an individual is seen to have purchased weight loss training products, it suggests that he or she has “change behavior” in mind. This can help identify people at risk when the chances of helping them can be maxmized, he says.

With the diagnoses codes changing due to healthcare reform and ICD-10, predictive modeling will have to be rebuilt, Preston notes.

"Lifestyle based analytics gives them a way to bridge that gap while this work is being done,” he explains.

For health insurers and providers, “the biggest hurdle,” says Stehno, is changing their “mindset and strategy” about how they approach people, and how they will use their existing programs to talk to people and reach out to them.

Things to Avoid During Menstrual Period

For women, having their menstrual period every month is like a burden. It comes with the untimely emotional bursts. There is a change to the hormones, metabolism and other body parts. Menstrual period is like a monthly update of your body. Some women have their period at the same time and date every month which makes it easier for them. 

But there are some things that you should avoid while you are on your period and these includes

1. Running 

Running won't be beneficial since you will only feel bloated

2.  Taking a shower

A warm bath will do if you don't want to stand up while taking a shower. 

3. Get out of the bed

It is okay to stay on your bed for a couple of days while you're on your red flag

4. Do housechores

Don't make yourself suffer if you really could not stand at all. Those chores could wait. 

5. Start Arguments

Since you are on your period you tend to say things that you really don't mean so let the things pass by. 

6. Watch chick-flicks

It will just make you emotional missing the life that you do not have right now. 

7. Eating lots of chocolates

You can eat a little, but eating a lot will just make you gain weight

8. Exercise

It would just ruin the exercise clothes that you have. You can start exercising if your period is already done. 

9. Use Phones

If you get too emotional you might end up talking to someone that you don't want to and say things that you don't mean. 

10. Cook 

Handling sharp objects such as the knife is not advisable since it can be dangerous for someone who is emotional.

India Introduces Injectable Polio Vaccine

From April, 2016 the trivalent polio vaccine that is currently administered will be replaced by the bivalent variety to reduce incidence of vaccine-derived polio virus. 

India is all set to introduce injectable polio vaccine (IPV) in its universal immunisation programme (UIP) in a phased manner from November. This will be over and above the oral vaccine. From April, 2016 the trivalent polio vaccine that is currently administered will be replaced by the bivalent variety to reduce incidence of vaccine-derived polio virus. India eliminated wild polio virus infection in January last year. In the first phase of IPV introduction, 17 high-risk states and four Union Territories will be covered. These are Bihar, Chandigarh, Delhi, Gujarat, Haryana, Punjab, Rajasthan, Uttar Pradesh, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura, Assam, Madhya Pradesh, Andaman and Nicobar islands, Lakshadweep, Dadra and Nagar Haveli and Daman and Diu. -

IPV is one of the three vaccines that were approved by the government for inclusion in the UIP more than a year back on the recommendation of the National Technical Advisory Group on Immunisation. The other two vaccines, measles-rubella and rotavirus are still in the works. “From November we will introduce IPV in the UIP schedule, in three phases, starting with the high-risk states. The single dose of the vaccine will be administered with the third dose of the DPT vaccine at 14 weeks. This is as per the global endgame strategy and also in preparation for our own switch to bivalent oral polio vaccine next year. For now, the administration of the oral vaccine will continue,” said a senior official in the Health Ministry. Oral polio vaccine is made of live attenuated polio virus of all three strains of polio – P1, P2 and P3. India currently uses the trivalent vaccine. The other variety, the bivalent one that India will introduce next year has only attenuated P1 and P3 strains. India eradicated P2 in1999 — the last case was in Aligarh — but the most number of cases of vaccine-derived polio happen because of P2. Till date about 44 such cases of polio derived from the vaccine have been reported in the country. That is why the switch to bivalent oral vaccine. IPV on the other hand is made up of killed polio virus and will give a child immunity from all three strains. There is no risk of vaccine-derived polio either.

In May 2012, The World Health Assembly endorsed the Polio Eradication and Endgame Strategic Plan 2013-18, calling on countries to strengthen routine immunization programmes and introduce at least one dose of IPV in all countries using only oral polio vaccine. IPV is to be given in addition to the existing oral polio vaccine, in order to boost population immunity. For the first year GAVI, which is an international vaccine alliance, has given about 28 million vaccine doses to India. This is against India’s original demand for 40 million doses to account for wastage, transportation etc. India’s total annual birth cohort is 27 million. The first instalment is not sufficient to cover all states but the government is hopeful of further support from GAVI. The target is to cover all states in the next seven-eight months. Continuing IPV without GAVI support will entail a cost of approximately Rs 200-250 crore.

Compared to oral form of polio vaccine, the IPV is also expensive with each dose costing anywhere between Rs. 100 and Rs. 120. According to estimates, the State and Central governments will be incurring an additional expenditure of Rs. 7.50 crore per year to administer the inactivated form of polio vaccine.

“Apart from completing the training part, we are almost through with the logistics part. The Government of India has given clear cut instructions to switch to IPV by April 25 and we will be able to meet the deadline in Telangana State,” says Chief Programme Officer, National Health Mission (NHM) in Telangana, G. Srinivasa Rao.

The existing oral polio vaccine, which is cheap and can be easily administered, uses live but weakened forms of the poliovirus. However, live vaccine viruses can occasionally revert to virulence and there is always a chance of having a ‘live’ polio virus in the community. With IPV, however, there are no such risks because the virus is already deactivated, doctors here clarified.

Senior paediatricians have also stressed on the importance of training workers on handling IPV and maintaining the cold chain, which is necessary, while the drug is being transported.

Age and Infertility

The average chance of becoming pregnant each cycle is only 20%.It takes 5 to 6 months for the average fertile couple to conceive. One out of every six couples has trouble conceiving and/or carrying a child to term. Over 1.2 million deliveries worldwide using assisted reproduction.

Women are born with all the eggs they will ever have. Some are ovulated, but several hundred are pre-programmed to die each month. Accelerated egg loss happens due to- smoking, ovarian  surgery, pelvic radiation, chemo agents.Irrespective of whether the patient is undertaking any fertility related treatment or not, there will be a decline in the ovarian reserve with age and its rapid especially after 30 years of age.That’s why the success of an fertility treatment is dependent of the age of the female partner.To determine fertility potential, we as clinicians are dependent upon the clinical,biochemical and sonological parameters that’s called as Ovarian Reserve Assessment(quality and quantity of eggs in a particular age range)

Trends

* Many women today are attempting pregnancy at older ages, when they are biologically less fertile.

* Pregnancy rates sharply decline after age 35.

* The exact age at which a  women can no longer conceive varies widely.

The trend in delaying fertility may be due to a greater emphasis on establishing a career, later marriages, and remarkable improvements in the area of contraception

Pregnancy rates related to age of female-

Woman’s Age (y)        % Conceiving in 12 Months

20-24                            86

25-29                            78

30-34                            63

35-39                            52

15 – 20% of  all couples will experience difficulties with conception, but this increases up to 50% at age 35 – 40.

Reasons Of Decreased Pregnancy chances with age-

* Conception rate of normal fertile couples (~ 20% /month)

Probability of clinical pregnancy following intercourse on most fertile day of cycle:

19-26 yrs old         50%

27-34 yrs               40%

35-39 yrs               30%

*Poor quality of aging oocytes

*Chromosomal abnl., morphologic abnl.

*Decreased ovarian reserve

*Altered hormonal environment- ovulatory dysfunction

* More conditions in older women- polyps,endometriosis, fibroids…

Sexual factors- decreased coital frequency

Treatment Options-

* Ovarian hyperstimulation with IUI generates more eggs and sperm to be present at the optimal time of conception.

* IVF (in-vitro fertilization)- vital to older when time         is critical , tubal pathology (live birth rate drop from 32% in women<35 10="" 41-42="" in="" nbsp="" p="" to="" women="" yrs="">

* Oocyte donation- option for older women Pregnancy rates are determined by age of donor, but   pregnancy complications by age of mother.

* Delaying childbearing may increase infertility and the chance of developing chronic medical conditions.

* If no pregnancy after 6 months of trying, refer to specialist!! Time is vital for these patients.

Risks to the prospective pregnancy-

There are various ways to quantify the risks associated with advancing maternal age-

There are multiple tests today to quantify a women’s risk of chromosomal abnormality:

* nuchal translucency

* first trimester serum screening

* quad screen in 2nd trimester

* invasive testing- CVS , amniocentesis

What patients need to know ?

As doctor, we are supposed to give clear picture to the patient about impending risks of adverse outcome of pregnancy in the form of

* preterm birth

* growth restriction

* stillbirths

Besides that we should discuss the risks of Hypertension, Diabetes mellitus, low  socioeconomic class….all influence outcome

Conclusion-

* Advanced maternal age is associated with reduced fertility and increased risk of adverse pregnancy outcomes.

* Associations are due to poor oocyte quality, age-related changes in uterine/hormonal function.

* Fortunately, the prospects for couples to conceive are better than ever with advancing age with advancement of science and introduction of ART and especially the Third Party Reproduction

Abnormal periods

If you have problems with your periods, talk to your GP as there may be treatments that can help.

Period problems include: 

absent periods (amenorrhoea)

heavy periods (menorrhagia)

irregular periods

painful periods (dysmenorrhoea)

Absent periods (amenorrhoea)

If a woman stops having periods altogether, it's known as absent periods or amenorrhoea. It usually means no eggs are being produced. If you don't produce eggs (ovulate), you can't get pregnant.

There are many possible causes of absent periods, including:

severe stress or illness

extreme weight loss or extreme exercise

various medications

polycystic ovary syndrome (PCOS)

Treating the underlying cause often leads to your periods resuming.

Heavy periods (menorrhagia)

The amount of blood lost during a period varies from woman to woman.

However, see your GP if your periods are so heavy that they're disrupting your life and making you feel miserable. Treatment may help.

You might have heavy periods if:

you're using many tampons or sanitary towels

blood leaks through to your clothes

you need to use a sanitary towel and a tampon to prevent leaking

you become anaemic – leading to tiredness, shortness of breath, feeling faint, or hair loss

Irregular periods

Periods can last between two and eight days. The menstrual cycle (the time from the start of one period to the day before the next one) usually lasts 24 to 35 days.

If you have irregular periods, the gaps between your periods will vary, as will the amount of blood you lose and how long your period lasts.

Irregular periods are caused by irregular ovulation, so there are many possible causes. They may be normal in puberty or shortly before the menopause, or may be caused by progesterone-based contraceptives. The other possible causes are similar to those of absent periods.

Treatment for irregular periods depends on the underlying cause.

Painful periods (dysmenorrhoea)

Most women experience painful periods at some point in their lifetime. The pain can be in your lower abdomen (tummy), pelvis, lower back, thighs and vagina shortly before and during your period.

The pain can vary from mild to very severe. Speak to your GP if the pain is severe and you're finding it difficult to cope.

Painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat painful periods.

Menstrual Cycle

Menstruation, also known as a period or monthly, is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. Up to 80% of women report having some symptoms prior to menstruation. Common symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes. These symptoms interfere with normal life, and therefore qualify as premenstrual syndrome, in 20 to 30% of women. In 3 to 8%, symptoms are severe.

The first period usually begins between twelve and fifteen years of age, a point in time known as menarche. However, periods may occasionally start as young as eight years old and still be considered normal. The average age of the first period is generally later in the developing world and earlier in developed world. The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women and 21 to 31 days in adults (an average of 28 days). Menstruation stops occurring after menopause which usually occurs between 45 and 55 years of age. Bleeding usually lasts around 2 to 7 days.

The menstrual cycle occurs due to the rise and fall of hormones. This cycle results in the thickening of the lining of the uterus and production of an egg which is required for pregnancy. The egg is released around day fourteen in the cycle and the thickened lining of the uterus is to provide nutrients for a potential developing baby. If pregnancy does not occur, the lining is released in what is known as menstruation.

A number of problems with menstruation may occur. A lack of periods, known as amenorrhea, is when periods do not occur by age 15 or have not occurred in 90 days. Periods also stop during pregnancy and typically do not resume during the initial months of breastfeeding. Other problems include painful periods and abnormal bleeding such as bleeding between periods or heavy bleeding.Menstruation in other animals occurs in primates, such as apes and monkeys, as well as bats and the elephant shrew.

A period is the part of the menstrual cycle when a woman bleeds from her vagina for a few days. In most women this happens every 28 days or so.

It's common for women to have a cycle slightly shorter or longer than this (from 24 to 35 days).

Girls have their first period during puberty. Most girls begin puberty between the ages of 8 and 14, with 11 being the average age. The first period is called the menarche.

A woman's periods continue until the menopause, which usually occurs when a woman reaches her late 40s to mid-50s (the average age is 51). 

The menstrual cycle

Each menstrual cycle starts on the first day of your period (day one) and lasts until the day before your next period begins.

The reproductive organs inside a woman's body consist of:

two ovaries – where eggs are stored, developed and released

the womb (uterus) – where a fertilized egg implants and a pregnancy develops

fallopian tubes – the two narrow tubes that connect the ovaries to the womb

the cervix – the lower part of the womb that connects to the vagina

the vagina – a muscular tube leading from the cervix to outside the body

During each menstrual cycle levels of the hormone estrogen rise as an egg develops and is released by the ovary (ovulation). Your womb lining thickens in preparation for a possible pregnancy.

The egg travels down the fallopian tube and if it meets a sperm and is fertilized, a pregnancy can occur.

The egg lives for about 24 hours. If it isn't fertilized, it will be absorbed into your body. The lining of your womb will come away and leave your body through the vagina mixed with blood. This is a period, also sometimes referred to as the menstrual flow or menses.

Symptoms associated with periods 

During your period you'll bleed from your vagina for a few days. The bleeding will usually be the heaviest in the first two days.

Your period can last between three and eight days, but will usually last for about five days.

The amount of blood you lose during your period depends on how heavy they are. It's usually about 30 to 72 milliliters (5 to 12 teaspoons), although some women bleed more heavily than this.

When the period is at its heaviest, the blood tends to be red. On lighter days, it may be pink, brown or black.

If you have heavy periods, there are a number of treatment options available. If your bleeding isn't too severe, you could try using a sanitary towel or tampon with a higher absorbency.

There are also a number of medications to help reduce bleeding. For example, the levonorgestrel-releasing intrauterine system (LNG-IUS) is a small plastic device that's inserted into your womb and releases a hormone called progesterone. It prevents the womb lining growing so quickly.

Alternatively, tranexamic acid tablets work by helping the blood in your womb clot.

Changes in your periods

Your periods can change – for example, they may last longer or get lighter. This doesn't necessarily mean there's a problem, but it does need to be investigated. You can go to see your GP, or you can visit your nearest women's clinic or contraceptive clinic.

Bleeding between periods, bleeding after having sex or bleeding after the menopause needs to be checked by a doctor. It might be caused by infection, abnormalities in the cervix (the neck of the womb) or, in rare cases, it could be cancer.

If you miss a period and you've had sex, you could be pregnant. See your GP if you're not pregnant and you've missed two or three periods. Find out about taking a pregnancy test.